- Physical illness (most common)
- Anxiety and depression
- Deliberately kept home by parents
- Miserable conditions at school e.g. Bullying
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Tuesday, 6 June 2017
Causes of school refusal in children
Summary of Treatment Guidelines for ADHD
Summary of Treatment Guidelines for ADHD
AAP Treatment Recommendations Nov 2019
Preschool children (4-5 years)
Methylphenidate, if no significant improvement and moderate-to-severe functional impairment
Elementary school (6–11 years)
Behaviour therapy or medication, preferably both.
stimulants > atomoxetine > guanfacine ER > Clonidine ER
Summary, NICE Treatment Recommendations 2018
Children under 5 years
Group parent-training program
(Only a specialist can start)
Start medications only after seeking advice from ADHD specialist services
Children over 5 years
Discussion and ADHD-focused Support
Offer a minimum of 1 or 2 sessions of support, can be
education on the causes and impact of ADHD
advice on parenting strategies liaison with school, parents, and carers
Before starting treatment, discuss with the carers
The benefits of a healthy lifestyle, including exercise The benefits and harms of non-pharmacological and pharmacological treatments Their preferences and concerns How other conditions affect treatment choices
Importance of treatment
Record the person's preferences and concerns
Ask if they wish a carer to join discussions
Reassure that they can revisit decisions
Children over 5
Lisdexamfetamine, after 6weeks trial off the methylphenidate
A 9-year-old child presented to you in the outpatient department, brought by his mother who was concerned because of his poor performance at school, saying his brother and sister are much more competent. On enquiry, she revealed that the child seems absent-minded, repeatedly loses items, does not seem to listen when being talked to, is fidgety and keeps running and bouncing ‘as if driven by a motor.’ His academic report revealed ‘below-average performance’ and he scored of 90 Weschler intelligence scale for children. The rest of the assessment was unremarkable.
What would be your recommendation?
The scenario best depicts a mild case of attention deficit hyperactivity disorder (ADHD).
Most patients will need psychosocial interventions and medications combined. However, the National Institute of Clinical Excellence recommends psychosocial interventions as the first choice of therapy. American Academy of paediatrics recommends psychosocial interventions as a primary treatment strategy for preschool children (4-5 years of age) and combined psychosocial and pharmacological treatments for older children. Both NICE and AAP recommend methylphenidate as the preferred medication if you must start one. Similarly, Canadian guidelines for the management of ADHD recommend psychosocial interventions before a trial of medication. They recommend methylphenidate and lisdexamfetamine as first-line medication. Nonetheless, patient individualization is important. For instance, if a patient has a comorbid tic disorder, clonidine will treat both the tic disorder and symptoms of ADHD, while stimulants may worsen the tics. Likewise, a patient with comorbid conduct disorder will need other specific interventions.
The best answer would be psychosocial interventions. Please let us know your thoughts. We have summarized the Recommendations of AAP and NICE on the next page.
Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD practise guidelines (CAP-guidelines) [Internet]. 3rd. Toronto: CADDRA; 2011.
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Paediatrics. 2011;128(5):1007-1022. doi:10.1542/peds.2011-2654
Overview | Attention deficit hyperactivity disorder: diagnosis and management | Guidance | NICE. (2018). Retrieved from https://www.nice.org.uk/guidance/ng87
- Anxiety disorder
- Conduct disorder
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